The Medicare patients Family Health Center already manages carry the conditions Medicare pays to manage between visits: hypertension in six of ten, high cholesterol in nearly half, diabetes in almost one in five. The practice sits inside a two-sided Shared Savings ACO that rewards the same work, and it already runs the annual wellness visit that opens the door. This is the 24-month plan to bill for that care inside NextGen, with CoachCare staffing the program, at no capital cost and with no new hire.
Two counts, two jobs. The headline is 590 unique patients at month 24; the enrollment chart and the Scenario Explorer show 905 active program enrollments, because a patient on both RPM and CCM is one patient and two enrollments.
A physician-owned family practice that has served Sandpoint for three decades, an NCQA-recognized medical home with same-day access and its own on-site lab, a Medicare panel whose own claims show the conditions remote care manages best, and a two-sided Shared Savings ACO that pays for keeping those patients out of the hospital. What is missing is the service line.
Six physicians, a nurse practitioner and two physician assistants at a single Sandpoint site, with a monthly diabetic group class, more than a thousand annual wellness visits a year, and a care team that already calls patients after a hospital stay. Every clinician is a referral source; the front door is already open.
CY2024 Medicare claims for the practice's clinicians show hypertension in 59% of beneficiaries, high cholesterol in 49%, diabetes in 18%, ischemic heart disease in 15%, chronic kidney disease in 14% and COPD in 9%. This is the panel the between-visit codes were written for.
CMS's own records place every one of the practice's clinicians inside a Medicare Shared Savings Program ACO on the BASIC track at Level E, a two-sided arrangement. Attribution runs on primary-care services, so documented monthly care management is what holds the panel and what moves the total cost of care the ACO is paid on.
The practice runs NextGen Enterprise with an active patient portal and online scheduling; CMS's 2026 quality file shows 82% of patients already have electronic access. The program integrates with the chart the clinicians work in every day. Nobody changes systems.
One structural fact completes the picture: no chronic care management or remote monitoring code appears at meaningful scale in the practice's CY2024 Medicare claims. The practice billed more than a thousand annual wellness visits and the same number of depression screens that year, and every one of the between-visit codes on the next page is absent. The panel, the conditions and the wellness-visit front door are here. The billing for managing those patients between visits is not.
Three things line up for an independent Idaho family practice in 2026: richer remote care billing, a two-sided ACO that pays for the same documented care, and a program model that needs neither capital nor a hiring plan to start.
New CPT codes 99445 (2–15 days of device data) and 99470 (the first 10 minutes of management) remove the 16-day floor that used to block episodic monitoring. A blood-pressure titration or a post-discharge window is now cleanly billable next to the standard monthly RPM stack. On this forecast the two new codes carry about 17% of remote-monitoring reimbursement.
Under the BASIC track at Level E the ACO shares in savings and in losses. Attribution runs on primary-care services, so the documented monthly touch that generates care-management revenue is the same touch that holds a patient's alignment and keeps a hypertensive or diabetic patient out of the hospital, which is where shared savings come from.
Enrollment outreach, care managers, devices and billing preparation are CoachCare's payroll, and fees are per active patient per month. For a practice whose own new-patient page says Medicare demand has grown the wait to get established, the program adds Medicare capacity and revenue without a build cost and without a hiring plan.
Medicare Advantage covers about four in ten Bonner County Medicare beneficiaries, so six in ten are still Original Medicare. MA plans must reimburse at no less than the Medicare rate, a floor; individual contracts set their own terms for the care-management code families. The forecast on this page is priced at the Medicare fee schedule for the whole panel; which plans hold the practice's Medicare Advantage members, and their terms for these codes, is the second thing to confirm after the chart count.
A named service line with its own P&L and scorecard, following the multi-chronic Medicare patient the practice already knows, inside NextGen. The panel runs on RPM and CCM, with transitional care at every hospital discharge the practice learns of. Family Health Center owns the program, its patients, its protocols and its revenue; CoachCare is the engine underneath it.
| Service | Codes | CY2026, Idaho locality | Use across the panel |
|---|---|---|---|
| Chronic care management | 99490 · 99439 | $62.47 + $47.52 add'l | The longitudinal wrapper; two or more chronic conditions |
| RPM setup and device supply | 99453 · 99454 · 99445 (new) | $19.68 setup · $47.79/mo | Hypertension, diabetes and heart-failure cohorts; 99445 opens 2–15-day windows |
| RPM treatment management | 99457 · 99458 · 99470 (new) | $48.66 + $39.14 add'l · $24.50 | Monthly review, titration, escalation |
| Transitional care management | 99495 · 99496 | $207.09 / $281.26 per discharge | Every hospital or observation discharge the practice learns of; not in the forecast below |
| Behavioral health integration | 99484 | $54.44/mo | The depression cohort the practice already screens; named as the next arm, not in any figure |
| Advanced primary care management | G0556 · G0557 · G0558 | $15.43 · $50.78 · $110.53/mo | Named as the next lever; not in any figure on this page |
Rates are the CY2026 Physician Fee Schedule non-facility amounts for ZIP 83864 (Noridian, Idaho statewide locality), the basis the Value Analysis below is priced on.
The practice runs NextGen Enterprise with an active patient portal and online scheduling. CoachCare integrates with it: eligible-patient flags and referral orders leave the chart, and monitored vitals, care documentation, enrollment status and billing-ready claims come back into it. The integration is bi-directional, scoped in a workshop with the practice's administrator and billing lead, and typically runs about four weeks alongside onboarding.
typical NextGen integration window, run in parallel with onboarding, training and care-team assignment.
a clinician flags an eligible patient and submits the referral from inside NextGen; CoachCare picks it up, ships the device and reaches the patient.
claims arrive billing-ready in the workflow the practice's own billing department already runs. No PDFs, no re-keying.
The Value Analysis shows the program pays. This is how it stays safe. Every blood pressure, weight or glucose reading and every CCM check-in routes through the same protocol, so the practice sees signal rather than noise, and a physician-owned practice keeps clinical control.
Chest pain, new shortness of breath, stroke signs, syncope, worst-ever headache, sudden swelling. CoachCare's urgent and emergent policy supersedes any client-specific preference. If the patient refuses, the practice is notified; otherwise CoachCare activates 911.
Out-of-range but not emergent findings route to the clinician or nurse the practice designates, with the readings, the symptom check and the recommended next step attached.
A retake that lands in range and a symptom check that is clean closes the loop with a chart note and nothing else. The clinician's inbox is reserved for what needs a decision.
An unreachable patient is re-attempted on a schedule, the practice is notified at every decision point, and a patient who stops transmitting is worked before a billing month is lost.
Any emergency room visit or hospitalization in the last 60 days triggers three touches inside two weeks. The practice's own medical-home standard already promises a call after a hospital stay, and its physicians round on their patients at the Critical Access Hospital a block away, so the discharge is one the practice sees. When the patient was admitted it is also the TCM episode: contact within two business days, the visit within 7 or 14 days. That cadence is where the modeled 60 avoided hospitalizations over 24 months come from, and inside a two-sided ACO each one is total-cost-of-care arithmetic as well as a patient kept home.
Reach the patient, reconcile medications against the discharge instructions, confirm the device is transmitting.
Symptom and reading review, barriers to the plan, follow-up appointment confirmed with the practice.
Close the episode or extend it; anything trending is escalated through the engine above.
A 24-month forecast for the RPM + CCM stack: a 2,500-patient Medicare panel with 2,000 in scope for Year 1, 9 referring clinicians plus CoachCare's enrollment outreach, Idaho locality rates, and the NextGen integration. Shared-savings distributions, TCM and APCM are not in these numbers.
| Program | Net reimbursement | CoachCare fees | Net to practice |
|---|---|---|---|
| RPM: devices, data and management | $823,340 | $489,094 | $334,246 |
| CCM: chronic care management | $911,391 | $474,924 | $436,467 |
| Implementation, NextGen integration and outreach | — | $36,187 | −$36,187 |
| 24-month total | $1,734,732 | $1,000,206 | $734,526 |
| Enrollment outreach, care management and device logistics are CoachCare's expense: embedded in the fee, never a separate charge to the practice and never deducted from its margin. | |||
24-month practice margin: 42.3% of net reimbursement (Year 1 41.5%, Year 2 42.9%).
Year 1 is $281,732 net to the practice on $678,934 of net reimbursement; Year 2 is $452,794 on $1,055,798. Month 1 is −$1,919; every month after month 2 is positive.
Recurring professional-fee volume over 24 months, generated inside NextGen.
Blood pressure and weight, a continuous picture of the hypertension and diabetes cohorts between visits.
About $905K in acute-care cost that never gets spent, at $15,000 per admission. Inside a two-sided ACO, that is total-cost-of-care arithmetic.
About 15,501 care-team hours of monitoring, outreach and documentation carried by the service line, not by the practice's nurses and front desk.
RPM reaches its ceiling of 455 enrollments in month 8 and CCM its ceiling of 450 in month 9. From there the census holds at 905 active enrollments, 590 unique patients, for the rest of the 24 months. The constraint on this forecast is the size of the eligible Medicare panel, not outreach capacity: a second enrollment specialist reaches the same ceilings sooner and adds $118,068 over 24 months, and it cannot raise them. What raises them is the chart count and the eligibility definition, which is why the working session starts there.
| Program | Enrollment ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 455 | 2,000 in scope × 65% eligible × 35% acceptance | Month 8 |
| CCM | 450 | 2,000 in scope × 75% eligible × 30% acceptance | Month 9 |
| At month 24 | 905 | Active program enrollments = 590 unique patients | — |
Eligibility is set for an adult primary care Medicare panel. Every point of eligibility or acceptance the practice's own chart data supports beyond these raises the ceiling, and the forecast, directly. On a panel where hypertension runs near 60% and the practice already counts more than two thousand hypertensives and six hundred diabetics in its quality measures, there is room.
The first lever is the chart count. The panel behind this page is sized from the practice's own Medicare claims and the Medicare Advantage share of Bonner County; a chart pull that shows more Medicare patients than that moves every figure on this page in proportion, and the Scenario Explorer is the tool for reading it off. The second is the eligibility definition: the share of the panel with a qualifying condition, which on this claims profile is conservative. The third is acceptance, which is where a thirty-year practice whose patients chose it on purpose has an advantage the model does not credit.
Advanced Primary Care Management (G0556–G0558) is Medicare's bundled monthly payment for the panel this program manages, and its value-model requirement is one the practice already meets through its Shared Savings participation. It carries zero dollars on this page. Once real enrollment data exists, the CCM-versus-APCM mix is the first design decision to make together.
CoachCare operates as the service line's engine while the practice's clinicians govern protocols and every clinical decision. Full-service delivery means launch needs no new headcount; the NextGen integration runs in parallel with onboarding, and the first enrollments follow the first referral orders.
NextGen integration built and tested; named program lead at the practice; P&L and scorecard; billing configuration with the in-house team; protocol sign-off for the hypertension, diabetes and kidney pathways; the ACO's care-management reporting aligned so the same touch counts on both ledgers.
CCM across the two-plus-condition panel and RPM for the hypertension and diabetes cohorts; CoachCare's enrollment outreach working the schedule and the annual-wellness-visit list alongside the practice's nurses; TCM and the post-discharge cadence live from day one.
RPM reaches its modeled ceiling in month 8 and CCM in month 9; monthly scorecard to the physician owners; the diabetic group class wired to the RPM data stream.
Re-validate eligibility against chart data, decide the CCM-versus-APCM mix, scope behavioral health integration billing, and align the program's documentation with the ACO's quality and cost measures.
CMS has proposed cutting the remote-monitoring device-supply codes for CY2027. The proposals are narrower than the headline. Here is what they do to the forecast on this page, priced at the Idaho locality amounts the forecast runs on rather than national averages.
The proposals reach the remote-monitoring family only. Chronic care management is not in them, and on this forecast CCM carries $911,391 of the $1,734,732 in 24-month net reimbursement. Its own amounts move by about two points, so $18,346 of the $97,487 total sits outside the remote-monitoring arm.
Two contingencies are already in build. An unbundled arrangement, with the software platform, device logistics and program enablement priced separately, and an MSO-style arrangement in which CoachCare manages the staffing while the practice owns the clinical program and the billing. Whichever way the final rule lands, the program does not have to be rebuilt.
CMS's ACCESS Model points at the destination: remote care paid as a risk-based per-member-per-month amount, with half of each payment withheld and reconciled against outcome attainment. Fee-for-service code cuts and that shift are the same policy argument. Pay for results rather than for device-months. A practice already inside a two-sided ACO is on the right side of that argument.
Three numbers, each smaller than the last, because each one sits on a larger base. Both bars are drawn on one shared dollar scale, so the colour can be compared directly across them.
24-month net reimbursement, CY2026 final versus CY2027 proposed, every code repriced at Noridian Idaho locality 00 amounts, non-facility, on this panel's own billing mix. Enrollment, acceptance and mix held constant. This is the rate change alone.
National non-facility amounts from the proposed rule's Addendum B, so the movement can be read without a locality in the way. The repricing above uses Idaho amounts; the two bases do not reconcile to the dollar, by design.
| In scope: remote monitoring | ||||
|---|---|---|---|---|
| Code | What it pays for | CY2026 | CY2027 | Change |
| 99453 | Setup and patient education | $21.71 | $20.03 | −7.7% |
| 99445 | Device supply, 2–15 days | $52.11 | $41.38 | −20.6% |
| 99454 | Device supply, 16–30 days | $52.11 | $41.38 | −20.6% |
| 99457 | Treatment management, first 20 minutes | $51.77 | $49.59 | −4.2% |
| 99458 | Treatment management, each additional 20 minutes | $41.42 | $40.39 | −2.5% |
| 99470 | Treatment management, first 10 minutes | $26.05 | $20.69 | −20.6% |
| Not in scope: care management | ||||
| 99490 | Chronic care management, first 20 minutes | $66.13 | $64.04 | −3.2% |
| 99439 | Chronic care management, each additional 20 minutes | $50.44 | $49.92 | −1.0% |
| G0556 | Advanced primary care management, level 1 | $16.37 | $16.09 | −1.7% |
| G0557 | Advanced primary care management, level 2 | $53.78 | $53.20 | −1.1% |
| G0558 | Advanced primary care management, level 3 | $117.24 | $116.91 | −0.3% |
The device-supply and short-treatment codes are held to a one-year maximum reduction by section 1848(c)(7) of the Act, which phases any decrease of 20 percent or more over two years. CY2027 is the capped year; the remainder of the crosswalk lands no earlier than CY2028.
The comment period on CMS-1848-P closed on September 14, 2026. The final rule publishes in early November 2026 and takes effect January 1, 2027. CoachCare led advocacy on the remote-monitoring provisions and will rerun this forecast against the final rates the week they publish.
The service line on this page runs on infrastructure already proven at national scale.
Over 400 managed conditions for 500,000+ patients.
Providers running remote care programs day to day.
Programs stood up and running in market.
Care-plan coding and billing behind more than 5 million claims.
Over 100 million vitals recorded; 4 million+ care actions enabled.
Six reasons this partnership fits Family Health Center specifically, not remote care in general.
CoachCare runs bi-directional integrations with the major certified EHRs, NextGen among them. Eligibility flags and orders leave the chart, vitals, documentation and billing-ready claims come back into it, and Phreesia stays exactly where it is. No second system for clinicians, no re-keying for the billing team, and no pressure to change platforms.
Enrollment outreach, care managers at about 160 patients each, device logistics, 24/7 alert triage and billing preparation are CoachCare's payroll. A practice whose own new-patient page says Medicare demand has grown the wait does not add a care-management hiring cycle on top; the program arrives staffed, at a 42.3% margin.
Fewer ED visits and admissions among attributed patients are what a two-sided ACO is paid on, and attribution runs on the primary-care services this program documents every month. The touches that generate care-management revenue are the same touches that hold alignment and produce shared savings. One program, both ledgers, with the fee-for-service margin funding it.
A recurring service line with its own margin is the alternative to selling the practice to fund the next hire. The revenue on this page is billed under Family Health Center, governed by its clinicians and owned by its physician owners. CoachCare supplies staff, devices, platform and billing preparation under that governance, which is the arrangement a thirty-year independent practice needs.
The practice runs more than a thousand annual wellness visits a year, which is the consent-and-enroll moment for chronic care management and the review where a device gets ordered. CoachCare's enrollment specialist works that list from day one, so the program fills from patients the practice already sees, not from cold outreach.
Fees are per active patient per month; there is no capital outlay and no payroll ramp. If the census does not build, CoachCare does not get paid, which is why the plan is measured twice before it goes to paper. The forecast, the Disclosures and the workbook behind this page are yours to keep either way.